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Tuesday, September 9, 2014

From the trenches: More about grit

The following was compiled from two comments on my recent post about grit written by a doctor who calls himself "Geronimo." It is reproduced with permission.

Grit cannot be assessed by a survey. I wholly agree. As a military physician, my firmly founded opinion is that grit is essential to the practice of medicine. Grit is the elusive characteristic that carries the clinician through the challenges that exceed ordinary capabilities. You cite a paper that argues for surgical training to borrow aspects of SEAL training. I applaud any measure that would allow senior faculty and program directors to unilaterally shape their residents’ training, whether or not it bears any resemblance to the rigors of BUD/S [Basic Underwater Demolition/SEAL training].

The 2011 loss of 30-hour call for medical students and interns was a fatal blow to residency training, in my estimation. I count myself fortunate for having a 30 hour call internship before embarking on my operational career. While downrange, it is not at all uncommon to be woken at inconvenient hours of the night to tend to the wounds of war. If you don’t know how you function cognitively, physically, psychologically, and emotionally while sleep deprived, exhausted, hungry, cold, and pissed off, you’re behind the curve. While it isn’t any fun to work in such a state, or to work with people so challenged, it is decidedly less fun to be a patient expiring for want of any medical provider, let alone a tired one. American medicine used to be in such a place in the not so recent past, to hear the story told by my forbearers.

How often does disaster visit that requires sleep be sacrificed? The headlines recount a few – Katrina, Boston Marathon, Tropical Storm Alison, 9/11. No doubt there were physicians stretched beyond their ordinary limits for each of those ordeals. How often does it occur that a physician or surgeon must work beyond their ordinary limits for a patient whose ill begot fate failed to generate the attention of the press? I’d be willing to bet it’s on a monthly basis at least.

You sir, are a senior practitioner, and physicians like you taught me the practice. You know better than I why long hours and challenging training are essential, sir. My only question, sir, is why residency training standards were diluted and degraded at the behest of nurses, OSHA, and likely other “powers that be”, when you knew it was the wrong way. Why don’t modern program directors, department chiefs, make a stand? If there exists widespread agreement that the current methods don’t meet the standard, why pretend that they do? If you are a retired PD, you have a privileged position as not having to fear retribution. Use your bully pulpit to build consensus, unify the opposition and mount the attack.

Your SEAL post had a comment from a Man’s Greatest Hospital surgery program director who lamented the demise of training standards in the same fashion. I find it demoralizing that PD’s have been rendered impotent in the face of these trends. Obviously this will require a near unanimous front of PD’s and department chiefs. If your generation matriculates from practice without this trend being reversed, I believe it will be too great a task for my generation to overcome.

And for what it's worth, I enjoyed the comments of TheTracker…

The utter incompetence of your generation—killing tens of thousands of patients every year with preventable errors secondary to the irrational systems, sloppily maintained, that you and your colleagues built up and managed.

Not to be blunt, but maybe while we're struggling to clean up your mess and catch up with the rest of the developed world, you could forgo your attempts to shift blame with anecdotes?

This is pure unadulterated nonsense. I really can’t figure out what he’s talking about, but would venture the guess that he is a fan of checklists, timeouts, shifts that don’t exceed 12 hours and bubble baths. I don’t live in his world, and don’t want to. I am a doctor.

All doctors faced an attrition rate that exceeded BUD/S trainees matriculation to operational SEALs. Among aspiring physicians, 80-90% or more, are weeded out through undergrad prereq’s, MCAT, and the like. It should be an arduous, stressful endeavor to become a physician, just the same as it should to become a SEAL. Lives depend on SEALs’ and physicians’ capacity to demonstrate grit. Bearing that in mind, we should demand the same high standards and control over how we bestow the privilege of practice on the next generation. As it has been said many times, it is harder to stay in Ranger Battalion/Special Forces Group/SEAL Teams than to become a Ranger/SF Soldier/SEAL. The same is doubtless true of surgery and medicine. Medical and surgical training programs should reflect that reality.

Tend to agree with Artiger. I for one do not want a tired and worn out, hungry, peeved doctor operating on me. I would rather have surgeons who are ok for level 1 treatment, doing certain things like gallbladders, etc. easy stuff and leave the harder stuff for others.

This type of bravado perpetuated amongst doctors is a bit dangerous in my opinion. US navy SEALS are designed to be killers, it's pretty much the worst example anyone could use to describe a program doctors should emulate. As a recent New York Times article (http://mobile.nytimes.com/2014/09/05/opinion/why-do-doctors-commit-suicide.html) addressing the death of two medical residents in New York City pointed out, this "Aequanimitas" that Osler originally described, has really been perverted by some programs. I have a tremendous amount of respect for senior faculty and staff who have sacrificed the best years of their life for the betterment of others, but don't tell me that working for 30 hours straight makes sense to anyone.

My biggest problem with the "grit" conversation is a semantic one. To me, "grit" is an abrasive irritant, something to be removed. "Grit" doesn't sound like a positive character trait. I'd prefer a term like "toughness" or "resiliency" or "persistence under pressure".

I agree with Geronimo on some points, but would like to make a clarification. I and many other program directors tried to get the powers that be (ACS,ABS, RRC, and most importantly department chairmen) interested in splitting off from the ACGME for accreditation as we were concerned with the effects that having mandated work hours would lead to. It is more than ironic that some Department Chairs have, after the fact, now suggested that residencies be accredited by the ACS rather than ACGME. If they had just listened.... To be clear, I personally didn't have a problem with decreasing work hours (I had changed the program from every other night call to every third night call as every other night just seemed unreasonable), but the arbitrary and dogmatic rules seemed to me (and others) to protend more and greater changes with no real proof of validity. Geronimo is right, it is demoralizing that the program directors are impotent, but when faced with "orders from above", we had to turn to "patriotic submission" (as described by Jubal Early)--a concept I am sure that Geronimo is familiar with as a military physician. My experience is that most of the remaining program directors actually believe in this BS. Personally, when the external, arbitrary rulings got to an extent that I felt I could no longer train truly outstanding surgeons, I chose to practice rural surgery. This had less to do with work hours than it did with required didactic sessions, simulation, and political correctness, and the desire to project the "right image" rather than to do the best thing. I'm sorry you are demoralized, Geronimo, but suck it up, I have.Charlie Ferguson, aka, Fergasorus

This is yet another example of why it's a good thing that generations die off. A great quote (can't remember who said it): "medical education changes one funeral at a time." There is substantial data showing that PREVENTABLE errors are the 4th leading cause of hospital deaths. If you don't think that has anything to do with the fatigue generated by overly long residency shifts, you are in complete denial. I don't want doctors who have been trained to see medicine as a battlefield where those who are most like Navy SEALS are admired. I admire people with knowledge, judgment, wisdom, patience, humility, and enough sleep and time off to maintain their physical and mental health, including time with family and friends. Punishment is not education; fatigue and excess stress do not enhance learning and retention!

BUDs training isn't about turning a normal person into a killer, it is about determining who will be able to complete complex tasks, under extreme duress, in a team setting, no matter what. Surgeries don't always cooperate with a Drs circadian rhythms, and knowing in advance who can remove an appendix on little sleep is probably better figured out early in the process.

Nobody is advocating for tired doctors, just ones who perform well when performing tired is the only option. Who can argue against the development of physicians who have some experience of these conditions--if, at the least, they come to understand that they *cannot* perform well while fatigued, and should go rural or start bulking up on their grits? -Jack

The last place a surgeon who can't operate when tired should go would be a rural practice. He may be solo or if lucky have only one other surgeon nearby. These guys take tons of call for years and are really unsung heroes.

Thanks for the repost. My apologies for being tardy in offering replies to the comments, I’ve been getting buried in clinic.

For those who have an interest in the topic, from either perspective, I’d like to point out that Dr. Scott Weingart has posted on his EM Crit podcast an interview with a former USAF Pararescueman, Michael Lauria, on the topic of resilience and stress inoculation training for residents.

http://emcrit.org/podcasts/toughness-michael-lauria-i/

Mr. Lauria is now a first year medical student. They have some interesting thoughts on what is possible to supplement medical training of residents in stressful, team based tasks such as the resuscitation of critically ill patients. I’ll let the interested parties take it from someone who has graduated from a SOF training pipeline. I am not in SOF, and never have been.

Grit or resilience in medical training is necessary for the same reason as in military training. Lives are on the line. Military training isn’t about punishment or sadism, if executed correctly. It’s about ensuring that trainees can accomplish a task under certain conditions. If you want success in difficult conditions, you need to train under difficult conditions. If you want patients to live through arduous surgeries or chaotic codes in the middle of the night, doctors need to be trained to do that.

There is nothing in life that was more terrifying than this: practicing at the limit of my skill, being the only physician for miles around, a handful of combat medics to man my trauma tables, trying to save a dying patient or patient(s). Getting shot at did not compare. After that experience, I hated myself for every morning conference where I was nodding off – whether I had been awake for 24 hours prior or not. Now I want the 36 hour Q3 call my uncle had in his training. I want the DeBakey ICU, where residents were constantly on call for a full two months. Its not fun, and its not easy, but neither is pronouncing death.

Once you hold the responsibility for a human life in your hands, and your hands alone, sleep just doesn’t rate. If a patient dies and your lack of knowledge, capability, mental faculty leads you to believe that you and you alone were responsible, you won’t be sleeping well anyway. We need to train hard in residency, while in a protected environment. Once you’re on your own, its too late.

I think part of the way in which we came to this cultural divide in medicine is owed to the ‘team approach’ and death of solo practice in many specialties due to the challenges of billing insurance companies for reimbursement, but that’s another topic.

Dr. Ferguson, I’m in full support of undermining the ACGME and pursuing ACS and other accrediting bodies for residencies. If this is a possibility, it should be pursued. OSHA, nursing unions, and whoever else have no place dictating how physicians are trained. I’m demoralized about the failure of medical leaders to make their voice heard, but not willing to concede.

Not sure I’d agree that it’s a “good thing that generations die off”. As it happens, I’m in my early thirties. Preventable error is a bigger story than fatigued residents. Further, the new restricted work hours have not been shown to reduce error or improve safety, and there’s a growing body of evidence on that point. Hard training is not punishment, and practicing medicine isn’t about being admired. Practicing medicine is about doing what is right by our patients. Sometimes that will mean tapping out because you know you are beyond your limits, and sending the patient to the surgeon in the next county over from your rural practice. If you haven’t met your limits before, you won’t recognize them as you go blazing past.

My argument is that residency training should be about how to remain patient, humble, and employ good judgment, knowledge and wisdom while sleep deprived. That is the task set before us in residency. If you don’t get it in residency, it’s damn hard to get it once you’re on your own.

Hi. I am a European surgical trainee from a European country. I was taught for work morale in the US and it truly serves me well here. Where Geronimo is right is that you definitely need a certain type of grit to do this job, especially acute surgery. Where he is not right are the hours. I did 48 hour shifts without any kind of real pause (except for a few brief hours of sleep from saturday to sunday, woken 1-2x in the night). Sunday afternoon at 15.00 hours I was hardly able to stay awake and the patients just kept coming. I was hardly friendly with them nor could perform as precise as at that time saturday.... Not to mention that it definitely damages your health and I am planning on retiring in 60 years from now and have a well deserved rest.Not to mention operations performed after sleeping in the hospital, if ever you get some. Earlier on, in the late 20th century people only came to the doctor's office if they were really sick. Now they keep turning up for everything. In my opinion if you are learning surgery you should not perform operations when you are tired or otherwise impaired. Just think about it. Do you drive drunk or when you are tired beyond your limits? No, because you will definitely hit something. I guess 30+ hour shifts would be okay, if you let people who are just getting their grips sleep for 6 hours without distraction and get on with the real-hardcore-not-sleeping stuff after the trainee has got some understanding from the stuff (e.g. from 2nd trainee year or something like that). Just think about it from your point of view guys: Do you want to work with a very engaged, but very tired guy, at the end of his 30+ hour shift who can hardly see let alone hold a scalpel?? He is just going to annoy you because he will be clumsy from not sleeping and his attention will be hampered from being tired. This leads to a vicious circle where the trainer gets annoyed and angry and radiates that to his trainee back who in turn will also be annoyed or at least distressed and the whole operation will go south. This is a very hot topic indeed in Europe as well. What I can say is that it is not the hours or generation y that screws up the whole thing, but the idiotic, zombie- like patients, who turn up for everything in ER. In these days sometimes we are more social workers than doctors in an outpatient unit.

Anonymous European, I see you have bought in to the system. Have you read my post on the 48-hour work week in the UK? http://skepticalscalpel.blogspot.com/2013/12/uk-doctors-work-hours-limits-are-fraud.html

It is apparently a sham. Do you ever work more than 48 hours in a week?